Question
Options if I am getting efavirenz side effects?
9 October 2008. Related: All topics, Changing treatment.
Dear i-Base,
I have been experiencing particularly unpleasant side effects from taking Atripla as of late, in relation to feeling depressed, mood swings, loss of appetite, lack of energy, my feelings of ‘euphoria’ and being ‘spaced’ have not subsided too. I have been signed off work for 2 weeks due to work related stress and the effects of the efavirenz.
I started taking Atripla in July this year with a CD4 count of 258 and viral load of 190,000 and my CD4 is currently 463 and viral load of 159 (as of 18/09/08).
My consultant has suggested TDM (Therapeutic Drug Monitoring) to see if i can take a smaller dose of efavirenz, but I am not convinced this will be the solution to the problems I am facing, and two choices of alternative combinations was suggested which are Truvada + nevirapine or atazanavir, ritonovir and Truvada.
I was told that I cannot have nevirapine at this stage as my viral load is not undetectable, and that due to my CD4 being relatively high, nevirapine is not the preferred choice. My question is why is nevirapine not recommended as I cannot seem to find any information about the correlation between a high CD4 count and nevirapine?
I have also concerns of taking the combination of Truvada, ritonovir and atazanavir, due to the problems associated with jaundice, Cardio vascular disease (if there are any) and the side effects of this combination.
Please advise,
Answer
You are right to do something as you shouldn’t have to put up with these side effects after several months. TDM is an option but it probably is easiest to try alternative drugs first.
Nevirapine is not recommended for people who start it when their CD4 count is above 400 for men and above 250 for women because of possible higher risk of liver toxicity. This is usually related to starting treatment for the first time (rather than switching). For more info see here (i-Base leaflet) and here (FDA leaflet). Your doctor is playing safely though and perhaps that is a good thing.
As for the PI, atazanavir is fairly easy to take and is mild on the lipids (less risk for cardiovascular diseases). If you are that worried about the yellowing of the skin, which affects less than 10% of patients, then lopinavir/r (Kaletra) is another option.
Currently, the risk of cardiovascular disease (heart attack and stroke) from HIV drugs are mainly linked to whether they increase blood lipids (triglycerides and cholesterol). These are routinely monitored for all combinations.
I recently switched from Atripla to Atazanavir, Truvada & Ritonovir because I developed side effects which didn’t seem to go away (mainly anxiety and feeling very sad all the time).
I have been on the new combination for 2 weeks. After a few days I started to get a slight yellowing – but most people thought I had been on a sun bed and thought I had a healthy glow! I know I’m only 2 weeks in, but I feel so much better than when I was on Atripla. Oh – and the yellowing went after a few days.
I have to admit, I would have prefered to stay on a 1 a day pill – but I would rather have a few pills and feel “normal”, than 1 pill and feel as low as I did.